Nokea
A client who is depressed states, 'I think my family would be better off without me. They don't need to worry.' Which would be the most appropriate response by the nurse?
- A. Are you planning to commit suicide?
- B. What do you think they are worried about?
- C. You don't mean that. Your family loves you.
Correct Answer: A
Rationale: Directly asking about suicidal plans addresses potential ideation, ensuring safety and opening further assessment.
You may also like to solve these questions
A client asks the nurse why he has to go to therapy and cannot just take his prescribed antidepressant medication. Which would be the most therapeutic nursing intervention?
- A. Stating, 'The effects of medications will not last forever. You will need to eventually learn to function without them.'
- B. Stating, 'Medications help your brain function better, but the therapy helps you achieve lasting behavior change.'
- C. Stating, 'Both are recommended. Since your insurance covers both, that is the best plan for you.'
- D. Asking, 'Do you have reservations about going to therapy?'
Correct Answer: B
Rationale: Therapy complements medication by fostering lasting behavioral changes, addressing underlying issues.
A client is being discharged on lithium. The nurse encourages the client to follow which health maintenance recommendations? Select all that apply.
- A. Weigh self weekly at the same time of day.
- B. Drink a 2-L bottle of decaffeinated fluid daily.
- C. Do not alter dietary salt intake.
- D. See the doctor if you get the flu.
- E. Restrict involvement in intense exercise.
Correct Answer: B,C,D
Rationale: Maintaining fluid intake, stable salt levels, and monitoring for illness prevent lithium toxicity and ensure therapeutic levels.
The client with mania attempts to hit the nurse. Which is the best response by the nurse?
- A. Do not swing at me again. If you cannot control yourself, we will help you.
- B. If you do that one more time, you will be put in seclusion immediately.
- C. Stop that. I didn't do anything to provoke an attack.
- D. Why do you continue that kind of behavior? You know I won't let you do it.
Correct Answer: A
Rationale: This response sets clear behavioral expectations and ensures safety without escalating the situation.
Which meal would the nurse provide to best meet the nutritional needs of a client who is manic?
- A. Peanut butter sandwich, chips, cola
- B. Fried chicken, mashed potatoes, milk
- C. Ham sandwich, cheese slices, milk
- D. Spaghetti, garlic bread, salad, tea
Correct Answer: C
Rationale: Finger foods like a ham sandwich and cheese slices are high in calories and protein, suitable for a manic client's mobility.
The nurse observes a client sitting alone at a table, looking sad and preoccupied. The nurse sits down and says, 'I saw you sitting alone and thought I might keep you company.' The client turns away from the nurse. Which would be the most therapeutic nursing intervention?
- A. Move to another chair closer to the client and say, 'The staff is here to help you.'
- B. Move to a chair a little further away and say, 'We can just sit together quietly.'
- C. Remain in place and say, 'How are you feeling today?'
- D. Say, 'I'll visit with you a little later,' and leave the client alone for a while.
Correct Answer: B
Rationale: Offering quiet companionship while respecting personal space conveys acceptance and supports the depressed client.